Lactational mastitis and breast abscess - diagnosis and management in general practice

Lactational mastitis Leila CusackMeagan Brennanand breast abscess
Diagnosis and management in general practice
EpidemiologyBackground
Lactational mastitis affects approximately 20%
Lactational mastitis is common, affecting one in 5 breastfeeding women. As well as
of breastfeeding Australian women in the first 6
causing significant discomfort, it is a frequent reason for women to stop breastfeeding.
months postpartum.7 It is most common in the first 6
Objective
weeks of breastfeeding1,5 with the highest incidence
This article outlines an evidence based approach to the diagnosis and management of
occurring during the second and third weeks.6,9 It is
lactational breast infections in general practice.
initial y localised to one segment of the breast, but
Discussion
untreated can spread to affect the whole breast.5
Lactational mastitis is usually bacterial in aetiology and can generally be effectively
Around 3% of lactating women with mastitis will
managed with oral antibiotics. Infections that do not improve rapidly require further
develop a breast abscess,1,10 although an incidence
investigation for breast abscess and nonlactational causes of inflammation, including
the rare cause of inflammatory breast cancer. In addition to antibiotics, management of lactational breast infections include symptomatic treatment, assessment of the infant’s
Risk factors and prevention
attachment to the breast, and reassurance, emotional support, education and support
The main risk factor for mastitis is breastfeeding
during the early postpartum period.6 Milk stasis
Keywords: mastitis; breast abscess; lactation; general practice
and cracked nipples may contribute to the development of mastitis,1,3–6 although the evidence for this is inconclusive.1 Other implicated factors include previous mastitis,6 maternal fatigue1,3 and
primiparity.9 Reported risk factors for breast abscess
process affecting the lactating breast.1–4
include a past history of mastitis, maternal age over
It is usually bacterial in aetiology. It
30 years and gestational age greater than 41 weeks.5
There are no interventions that have been
localised pain, tenderness, erythema and
consistently proven to prevent mastitis. Encouraging
engorgement,3–6 and may be accompanied
emptying of milk from the breast is often
recommended, however, evidence for its efficacy
malaise, rigors, nausea and vomiting.4–8
is inconclusive.6 The most commonly practised intervention is the prevention and management of
A breast abscess, a localised collection in the
damaged nipples; in some settings this may reduce
breast tissue that results in a painful breast lump,
the risk of developing mastitis.3 A Cochrane review
is potentially secondary to bacterial mastitis
found that anti-secretory factor cereal, mupirocin
that is rapidly progressive or is not managed
ointment, fusidic acid ointment and breastfeeding
expeditiously. Effective management is essential
advice had no significant impact on the initiation
to control the discomfort and reduce the likelihood
or duration of breastfeeding or the incidence of
of discontinuation of breastfeeding, which may
occur as a consequence of mastitis.6,7 Mastitis
Microbiology
and breast abscess may develop in women who are not breastfeeding; this article will focus on
The most common causative organism for mastitis
is Staphylococcus aureus.8,10 Strains of methicil in
976 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011
Lactational mastitis and breast abscess – diagnosis and management in general practice CLINICAL
resistant S. aureus (MRSA) have been identified,
may distinguish inflammation (mastitis) from a
lump remains, no fluid is obtained or fluid is
particularly in hospital acquired infections. Other
collection of pus in the breast (abscess) (Figure
bloodstained rather than purulent, then core
organisms include streptococci and S. epidermidis.
2). Ultrasound also al ows guided aspiration of
biopsy is recommended to exclude breast cancer.13
Patients who suffer with recurrent breast abscesses
any abscess providing drainage and fluid for
Mammography is not a first line investigation
have a higher incidence of mixed flora, including
microscopy and culture. A malignant lesion may
in lactating women but is indicated if there are
anaerobic organisms.5 On rare occasions Candida
mimic an inflammatory col ection on ultrasound.
clinical, sonographic or biopsy features suspicious
albicans, not an uncommon cause of nipple pain in
Hence, fol owing aspiration, if a significant
lactating women,9 can cause parenchymal infection.12
Clinical assessmentHistory and physical examination
Breast pain is the primary symptom of mastitis.7 High fever is common, along with other generalised flu-like symptoms including malaise, lethargy, myalgia, sweating, headache, sometimes nausea and vomiting and occasionally rigors.1,5–7
Clinical examination of the breast should focus
on looking for signs of inflammation (erythema,
Figure 1. Mastitis is characterised by a
Figure 2. Ultrasound of a breast abscess.
localised tenderness, heat, engorgement and
swelling) (Figure 1) and signs of nipple damage.
Photo Science Photo Library, 2011. All
General observations including temperature, pulse
and blood pressure are important to exclude sepsis, which requires hospital admission.Table 1. Common breast problems in the puerperium
Breast abscess is characterised by symptoms
Benign conditions
similar to mastitis, with the additional sign of
Conditions related to lactation
a discrete tender lump, which may be tense or
fluctuant. The mass may have overlying skin
s¬ "REAST¬INFECTION¬MASTITIS¬OR¬ABSCESS
necrosis suggesting that the abscess is ‘pointing’
– bacterial infection – usually S. areus
(abscess is sitting close to the surface of the skin).
¬ n¬FUNGAL¬INFECTION¬C. albicans¬UNCOMMON
Less frequently, breast abscess presents as a non-
tender lump without erythema (‘cold abscess’).
s¬ 'ALACTOCOELE¬NONINFECTED¬MILKFILLED¬CYST
Examination of the infant and attachment to the breast
¬ n¬CRACKEDDAMAGED¬NIPPLES¬ – incorrect attachment: misalignment of mother’s nipple and baby’s mouth
The infant should be examined to ensure adequate
¬ n¬INFANT¬CAUSES¬POOR¬SUCKING¬TONGUETIE¬CLEFT¬PALATE
growth and hydration. Examination of the baby’s
mouth can exclude candida infection (white film
adherent to the buccal mucosa),2 or anatomical
Other conditions
conditions such as cleft palate or tongue-tie which
s¬ ¬"ENIGN¬BREAST¬DISEASE¬FIBROADENOMA¬FIBROCYSTIC¬CHANGE¬CYST¬BENIGN¬PHYLLODES¬
may interfere with attachment.6,9 Observation of
breastfeeding can determine if there are difficulties
with attachment to the breast. A lactation
¬ n¬TENDER¬COSTOCHONDRAL¬JUNCTIONS¬4IETZE¬SYNDROME
– sleeping or breastfeeding in an uncomfortable position
Investigation Malignant causes
Mastitis is a clinical diagnosis and investigations are not indicated in the initial assessment.1
with a course of appropriate antibiotics should
¬ n¬¬INFLAMMATORY¬BREAST¬CANCER¬MAY¬MIMIC¬BACTERIAL¬MASTITIS ¬
be investigated with breast ultrasound.5 This
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 977
CLINICAL Lactational mastitis and breast abscess – diagnosis and management in general practiceDifferential diagnosisTable 2. Management approach to breast infections
Other less common breast problems may present in the puerperium (Table 1). These differentials should
Clinical assessment
be kept in mind, particularly if the clinical features
s¬ ,OCALISED¬INFLAMMATORY¬FEATURES¬PAIN¬ERYTHEMA¬HEAT¬SWELLING ¬s¬ 3YSTEMIC¬FEATURES¬FEVER¬MALAISE¬MYALGIA
s¬ !SSESSMENT¬OF¬INFANT¬HYDRATION¬AND¬WEIGHT
Symptom management
presentation but should be considered if mastitis is
not responding to treatment1,2 (Figure 3). Nonbreast
causes of fever (such as urinary tract infection
or endometritis, ie. fol owing complications of
Antibiotic therapy
Caesarean delivery) should be considered where the
s¬ Flucloxacillin or dicloxacillin 500 mg qid for at least 5 days
presentation is with fever rather than breast pain
s¬ For abscess – guided by microbiological culture and sensitivity
Support continued breastfeedingManagement
s¬ %DUCATION¬AND¬REASSURANCE¬s¬ 2EGULAR¬AND¬COMPLETE¬DRAINAGE¬OF¬BREAST¬USE¬BREAST¬PUMP¬IF¬NEEDED ¬
The key components of management are symptom
control, oral antibiotics and encouraging continued
milk flow from the affected breast (Table 2). The
s¬ 2EFERRAL¬TO¬!USTRALIAN¬"REASTFEEDING¬!SSOCIATION
patient should be reassured that antibiotics and
Early and frequent review
simple analgesics wil not harm her baby. Women
s¬ 2EVIEW¬IN¬n¬HOURS¬INVESTIGATE¬IF¬NOT¬SETTLING
should be encouraged to continue breastfeeding, to
s¬ ¬)F¬NOT¬SETTLING¬ULTRASOUND¬TO¬LOOK¬FOR¬BREAST¬ABSCESS¬AND¬RARE¬CAUSES¬OF¬
rest whenever possible and to drink plenty of fluids.
inflammation such as inflammatory breast cancer
Close monitoring is required to ensure that the
s¬ "IOPSY¬LESIONS¬SUSPICIOUS¬FOR¬MALIGNANCYManagement of breast abscess if presentManagement of symptoms
s¬ ¬!SPIRATION¬WITH¬ANTIBIOTIC¬COVER¬IS¬A¬SAFE¬FIRST¬LINE¬APPROACH¬WHERE¬SPECIALIST¬
Simple analgesia
breast clinics or ultrasound guidance are available
s¬ Incision and drainage if not settling or aspiration is unavailable
Regular oral paracetamol is first line treatment.
s¬ /THER¬MANAGEMENT¬AS¬PER¬MASTITIS ¬
Nonsteroidal anti-inflammatory drugs can be added.
Psychological supportHot and cold packs to breast
s¬ %VALUATION¬FOR¬DEPRESSION¬s¬ 2EFERRAL¬TO¬!USTRALIAN¬"REASTFEEDING¬!SSOCIATION
Evidence is inconsistent, however, breastfeeding authorities recommend:
sæ APPLICATIONæOFæCOLDæPACKSæAFTERæFEEDINGæMAYæHELPæ
options include cephalexin or clindamycin.15
sæ GENTLEæMASSAGEæANDæWARMæCOMPRESSæPRIORæTOæ
Alternatives used overseas include amoxycillin/
Cabbage leaves have demonstrated inconsistent
clavulanic acid and macrolides (erythromycin,
effects; producing postfeeding symptom relief
clarithromycin).5 Avoid tetracycline, ciprofloxacin
similar to-ice packs in some studies,5 while
and chloramphenicol as they are unsafe for use in
lactating women.5 Hospitalisation for intravenous antibiotics is rarely required but is indicated if
Antibiotic therapy
there are systemic signs of sepsis.5,15 Candida is a
Adequate antibiotic therapy is essential. Where
rare cause of mastitis and is characterised by the
possible this should be guided by microbiological
presence of intense pain, particularly noted after
culture and sensitivity (such as when fluid is
the breast empties, and the absence of breast
aspirated from an abscess).14 As S. aureus is the
common causative organism, antibiotic therapy
Figure 3. Inflammatory breast cancer may
Support for continued
of choice at least 5 days of flucloxacillin or
mimic mastitis. Classically it presents with a
breastfeeding
poorly defined clinical mass with erythema,
dicloxacillin in a dose of 500 mg four times per
skin thickening and peau d’orange (‘orange
day.15 Due to antibiotic packaging in Australia
The aim of therapy is to continue breastfeeding
this may require two consecutive 6 day courses
and to empty the breast as fully as possible with
Photo Slaven, 2011. All rights reserved
of antibiotics. For patients allergic to penicillin,
each feed. This relieves symptoms and reduces
978 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011
Lactational mastitis and breast abscess – diagnosis and management in general practice CLINICAL
the likelihood of progression to breast abscess.Identification and drainage of
breastfeeding women including telephone and email counselling and helpful resources:
There is no evidence of risk of harm to a healthy
breast abscess
sæ æ"REASTFEEDINGæ(ELPLINEææMUMææMUMææ
infant feeding from an infected breast.1,4,6 If
Lactating women with a breast abscess often
attachment is painful, a breast pump can be used
present late when the abscess is established and
to drain the breast until the infection settles
of large volume.5 The traditional management of
sæ ,ACTATIONæ2ESOURCEæ#ENTREæWWWLRCASNAUæ
enough to allow the baby to feed from the breast
breast abscess was surgical incision and drainage
(Figure 4). Infant attachment to the breast should
under general anaesthetic. This has been largely
Leila Cusack BSc, MBBS(Hons) is a junior medical
be checked and corrected. Referral to a lactation
replaced by percutaneous (outpatient) aspiration
officer, currently living in Europe. [email protected]
consultant may be helpful. The Australian
under local anaesthetic where specialist breast
Breastfeeding Association is also useful for
clinics or radiology services are available.
Meagan Brennan BMed, FRACGP, DFM, FASBP,
mother-to-mother support (see Resource).
Surgery can usual y be avoided and outcomes
is a breast physician, The Poche Centre, North
are better for outpatient clinic management
Sydney and Clinical Senior Lecturer, Northern
women choose to cease breastfeeding. These
than surgical management (including reduced
Clinical School, Sydney Medical School, University of Sydney, New South Wales.
women should be supported in their decision and
pain and scarring and increased likelihood
encouraged to wean gradually, preferably after
of continued breastfeeding).5,10,14 Access to
Conflict of interest: none declared.
the infection has resolved. Sudden cessation
specialist breast clinics may be limited in some
References
of breastfeeding may exacerbate the infection,
areas, particularly in rural areas, so surgical
1. Academy of Breastfeeding Medicine Protocol
increasing the risk of abscess formation.1,4
incision and drainage may be the treatment of
Committee. ABM Clinical Protocol #4: Mastitis.
Medication to suppress milk production is not
Revision, May 2008. Breastfeed Med 2008;3:177–80.
2. Amir LH. Breast pain in lactating women: mastitis or
Psychological issues
something else? Aust Fam Physician 2003;32:141–5.
3. Amir LH, Forster DA, Lumley J, McLachlan H. A
Early and frequent review
As well as the severe physical pain, mastitis
descriptive study of mastitis in Australian breast-
feeding women: incidence and determinants. BMC
Women with mastitis should be reviewed within
is often associated with complex emotions. It
24–48 hours to ensure that the inflammation is
occurs at a time of great physical, hormonal
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settling. If minimal improvement occurs, breast
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ultrasound is indicated (Figure 2). Ultrasound
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5. Dixon JM, Khan LR. Treatment of breast infection.
about milk supply have been associated with
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8. Francis-Morrill J, Heinig MJ, Pappagianis D, Dewey
their milk is extremely valuable to the health of
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of free information and support and women
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should be encouraged to use this resource.
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al ow urgent referral for specialist management.
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Resources
The Australian Breastfeeding Association provides
advice for health professionals and support for
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 12, DECEMBER 2011 979

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